South London Care Home Pioneer programme
Expression of Interest Form

I would like a place on the South London Care Home Pioneer programme (see dates below)

Name / Full Name
Name of home you manage / Care Home
Location / London Borough
Owner of home you manage / Home Owner
Address / Street
City Post Code
Phone number / Phone number
Email / Email

The South London Care Home Pioneer programme is for Managers of Care and Nursing Homes for Older People. I confirm that I manage a:

☐ Residential care home for Older People

☐ Nursing home for Older People

The home I manage has:

Beds / Approximate number
Residents / Approximate number
Residents over 65 years old / Number of residents


The home I manage is part of a care home group:

☐Yes ☐No

I hold Registered Managers Award (RMA) or equivalent:

☐Yes ☐No

Please give details of any previous leadership training you have undertaken.

Click or tap here to enter text.


I would like to join the programme because:

Click or tap here to enter text.

Declaration

I confirm that:

  1. I have the support of the owner of the care home I manage/my line manager to take part in the My Home Life Suffolk leadership development programme.
  2. I understand that by participating in this programme I will make every effort to attend all of the required sessions as non-attendance may jeopardise the success of the programme and the benefits to me and the care home I manage.
  3. I understand that it is free to enrol on the programme; however, reasonable charges may be applied for non-attendance unless there is proof of mitigating circumstances.
  4. I understand that spaces are limited and cannot be reallocated to another manager if I withdraw from the programme.

Signed: ______Print name: Print Name Date: Select date

Please ensure that your completed expression of interest form is returned by 17 November 2017 to Don Shenker on (Tel. 020 7188 7188 x57027).

Programme dates and information

MHL South London Cohort 1

DATES (provisional)

4-day Workshop

24, 25 OR 30, 31 January 2018

21, 22 OR 27, 28 February

Action learning sessions (half day)

Thursday 22 March 2018

Thursday 19 April

Thursday 24 May 2018

Thursday 14 June 2018

Thursday 19 July 2018

Thursday 20 September 2018

Thursday 25 October 2018

Validation Day

Thursday 22nd November 2018

Location

TBC, likely to be London Bridge

Facilitators

Danuta Lipinska & Don Shenker